The Case for Being Uninsured

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By: Jane M. Orient, MD

Republicans say they are going to “replace” ObamaCare, but they will come up with something very similar and at least as bad if they start with the same misguided objective: “universal coverage.”

There are necessities of life, but insurance is not one of them.

Just what good is that little card in your wallet? Once it has expired, it is good for absolutely nothing, even if you have paid $100,000 or more for it over a period of years.

It might be a ticket to get you into certain medical facilities, but in these days of narrow networks, it will keep you out of others. It by no means guarantees that the facility will provide you with the care you need or want—or even that you won’t get an outrageous bill, especially before you meet the deductible.  It will guarantee that you will be paying for a lot of things you don’t need or want. Some will be other people’s medical care, or anti-tobacco lectures, or alcohol rehab (even if you are a teetotaler).

You’ll pay for some things just because they are “quality” metrics—hospice evaluation is a newly proposed one. And you will definitely pay for administrators, managers, monitors, clerks, claims processors and re-processors, etc., all of whom get their paycheck or their pension even if your doctor doesn’t.

Many people choose to be uninsured, even if they are a good risk and can afford insurance, and more end up uninsured because they are a bad risk or can’t afford it, or simply choose to use their money for something else. In 1940, less than 10% of the population had health insurance.

You could go your whole life, and never miss that insurance card.

Most people, of course, do need medical care at some point. If they are uninsured, they can go to the doctor and whip out their checkbook, just like your mother or grandmother did, and just like you probably do at the veterinarian’s, the dentist’s, the massage therapist’s, or the mechanic’s.

The best reason for having insurance of course is the unexpected accident or catastrophic illness. Oh how I miss my AAA catastrophic policy that I had for years. It cost about $250/year and had a $25,000 deductible but promised to pay about $1,000,000 above that. They changed the rules and started requiring a “basic” (or “comprehensive” policy), which would cost about $10,000. So I said no thanks, and increased my automobile policy to the maximum medical coverage.

There’s still the risk of an expensive medical illness. What then?

I have actually bought quite a lot of medical care and paid out of pocket, although I have never filed a medical insurance claim. For one reason or another, insurance probably wouldn’t have paid anyway. And if you ask, the cash price is often quite reasonable, and the service prompt and courteous.

But what about something really expensive, like surgery or cancer therapy? Options include medical “tourism” abroad or in the U.S. Look for a price online, for example on MediBid.com or Surgery Center of Oklahoma (surgerycenterok.com), or ask in advance at facilities of your choice.

One option is to do without. Sound terrible? Well, it would be the patient’s choice, not President Obama’s deciding the patient would be better off with the “pain pill.” Nor would it be the insurer’s decision that the care was “unnecessary,” “inappropriate,” “not prudent,” or “experimental.” And of course if you decided to do without, you’d still have your money, not having paid it to the insurer in advance in exchange for a worthless promise.

There’s the risk of a bona fide emergency, with no time to think about the cost. Fortunately, these days you’ll still get the care in the U.S. If you have assets, you might have to sell them to settle your hospital bill. But consider this: would you rather buy a nice car and risk having to sell it to pay a bill, or pay the insurance company the same amount and never get to drive the car? If you have to borrow money to pay a bill, the interest is likely less than the amount it costs to funnel the money through a third party. And charity or cost-sharing ministries help a lot.

If most bills were paid directly instead of through a third party, medical care would cost far less. Wouldn’t that be better for everybody?

Everybody—except those who profit from gaming the system.

Cancer patients’ stories are featured. But they would probably be worse off with universal third-party payment.

Too much “insurance” (third-party payment) is the problem—not the solution.

The right to be uninsured is a necessary safeguard—not a threat to the system.


Jane M. Orient, M.D. obtained her undergraduate degrees in chemistry and mathematics from the University of Arizona in Tucson, and her M.D. from Columbia University College of Physicians and Surgeons in 1974. She completed an internal medicine residency at Parkland Memorial Hospital and University of Arizona Affiliated Hospitals and then became an Instructor at the University of Arizona College of Medicine and a staff physicianat the Tucson Veterans Administration Hospital. She has been in solo private practice since 1981 and has served as Executive Director of the Association of American Physicians and Surgeons (AAPS) since 1989. She is the author of YOUR Doctor Is Not In: Healthy Skepticism about National Healthcare, and the second through fourth editions of Sapira’s Art and Science of Bedside Diagnosis, published by Lippincott, Williams & Wilkins.

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  • wfmcfp

    If health insurance was like automobile insurance…..it might work out better for all.

    Automobile insurance does not cover: A set of new tires, transmission work, oil changes, lubes, windshield wipers, radiator leaks, or exhaust failures. If it did, our auto insurance would cost far far more than it does. When one owns a car, one expects the routine automobile expenses.

    Why not provide a legitimate major medical plan which covers only: Medically necessary surgeries, fracture care, hospitalizations, cancer treatment, diagnostic procedures, and truly “emergent needs” (not patience-less urgent care). Instead of my wife and I being charged $2200/month with a $10,000 deductible (no joke!)….we’d pay, say, $500/month and have a $3000 deductible. AND we’d also pay for routine primary care needs, screening procedures, colds, coughs, flus, immunizations, etc… I’m in!

    Also, the government needs to either stay out…or…stop the discrimination (I prefer they stay out). Tax brackets are supposed to “level the playing field” between income levels,….but they never seem to level anything, as those with higher incomes (especially small business/sole proprietor folks) ALWAYS are excluded from any subsidies/breaks ( kids college help, health care needs, group plan insurance benefits, etc..etc..).

    As a solo rural FP our state’s BCBS has just announced they are discontinuing all single family policies for 2017. Our state health care online market gave us a quote of $2300/month and being solo I have no group rate access,….so we will go without in 2017. The ACA has produced a 37% income reduction so far this year…(increased subsidized health care at MA reimbursement levels)…so I now take care of more patients receiving huge subsidies for the same health care I choose not to “afford” at $37,000 / year before I receive help. “Affordable”…

    A patient just this week told me he’d lost his BCBS as well so he too
    went on line…and, as small business owner who due to accounting laws
    can own property yet not show it as income, told me he is able to get the exact
    same ‘online’ insurance I was looking at for ONLY $200/month, as “Obama
    is paying for” $2100 of his monthly premium! Man, this really irritated
    me to hear this. And I’m taking care of him… 🙁

    I agree with the article’s author as I’m not at all confident the GOP lawmakers know how to fix this health care mess. Too many cooks in the kitchen…and not a genuine willingness for everyone to be involved in the fix, ….including physicians, insurance companies, patients, etc..

  • TR

    This is excellent. Patients/consumers need to have a choice. I was at a lecture about health care reform awhile back and the question was asked “Why are insurance companies needed to manage the care? The costs of care have increased and these companies – at least the ones that have stayed with it – are really making the bank!” The answer was “They have all the data.” It seems like that is just not correct, and even if it were, who needs all this data? I understand that whoever is paying the bill for a larger group of people – employers and state governments for example – want accountability. But why does everything have to go through the insurance company? This seems to be a very complex way to do things and it seems like there would be a big incentive for the middle man to want to stay there! Wow. Thanks for this great article!

  • Web Watchers

    Another thing I greatly dislike is the “mandatories” of health care. For example, AMA… refusing a treatment or discharging yourself “against medical advice.” This threat of losing insurance coverage – or worse, a new mother with no complications wanting to leave the hospital early (for some reason they want to wield their power and require 4 days in the hospital) and say “you have every right to discharge yourself but we will report you to CPS (child protection agency), this intimidation – THREATS that they do follow through with – are happening all the time and are unjustified.

  • BernieFlatters

    My experience with my provider, which I previously paid through insurance, and now with cash, is that they they look at cash payers dubiously, and the discount is not all that great. And good luck trying to shop around. Most of the time you can’t ask about prices without booking a complete appointment to get the estimate.

  • Alexander Freylicher

    Many people would choose to be uninsured and shop around for medical services if the providers, such as doctors, labs, etc., were required to a)give cost estimates b) charge all the patients essentially the same price as insurance companies.

    Currently, if you go to a car mechanic, he will not start working on your car until you sign written estimate. Not so the doctors. Most of them will never tell you how much they will charge even for routine procedures, although they know exactly how much insurance will pay them. If you do not have insurance, they may charge you 10 times more. A routine blood test will typically cost you $500, while the lab will be more than happy to get $50 from your insurance company. So, even if it is applied to your deductible, having insurance protects you from an equivalent of highway robbery by medical providers.

  • Jennifer Mercuri

    How would low wage workers afford health care? Are doctors and hospitals willing to barter services or accept low payments over time? When you can barely afford a vehicle, don’t own your own home, can barely put food on the table or clothe your family-how can you pay for medical treatment? I have seen the result of deferred treatment many times in the ER, and have seen friends without insurance put off potentially life threatening issues due to lack of funds. When the sliding scale clinics disappeared in the Reagan era, they never came back…very little access to health care for the poor-in our town there is only 1 sliding scale clinic and there is a 1 yr. + waiting list. In the last town I lived in the local HD couldn’t provide any services except to those with chronic illness since they were completely overwhelmed by diabetics and hypertensives with no coverage.
    WHERE are the POOR supposed to go? MDs and even ARNPs require payment at time of service, often even if you have insurance…
    What is your solution?

    • Jennifer Mercuri

      And it is silly to suggest that doctors and hospitals would lower their costs if they were being paid in cash…Don’t know too many MDs that would even consider that…

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